Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND RETAINED FOR AT LEAST ONE MONTH . Checklist must be completed by a CSE Competent Person.

1. IDENTIFICATION

  • Date and Time of Entry

  • Entry/Access Permit Number

  • Confined Space Location

  • Description of Works

  • Manhole No

  • Site Photo

2. PERSONNEL

  • Enter the names of Entry Personnel and Expiry Date of CSE Ticket

  • Enter the names of Surface Personnel and Expiry Date of CSE Ticket

  • Relevant Emergency contact numbers are accessible on site ?

3.ISOLATION

  • Electrical Isolation Required

  • Mechanical Isolation Required

  • Contact with System Operator Required

  • Required Isolation in Place - Checked by

  • Signiture

4. ATMOSPHERIC TESTING

  • Gas Detector Calibration Date

  • Recommended Levels

  • Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

  • Record Peak Test Readings Prior To Entry

  • Oxygen (%)

  • Explosive Gas (LEL%)

  • Hydrogen Sulphide (ppm)

  • Carbon Monoxide (ppm)

  • Other Gases Tested

  • Record any

5. VENTILATION

  • Natural

  • Forced

  • Wash Down

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE

  • Select any of the following that will be taken into consideration before entry into the Confined Space

  • Weather

  • Traffic

  • Noise

  • Catchment

  • Flow Volume

  • Trade Waste Discharge

  • Industrial/Commercial Discharge

  • Domestic Discharge

7. PERSONAL PROTECTION EQUIPMENT

  • Select relevant PPE to be worn or carried by persons entering the Confined Space.

  • First Aid Kit

  • Helmet, Boots, Safety Vest

  • Gloves

  • Eye Protection

  • Hearing Protection

  • Overalls, Chemical Suite

  • Waders

  • 2 Way Radio

  • Gas Detector

  • Self Rescue Respirator

  • Fall Arrest Device

  • Lifeline

  • Harness

  • Airline

  • Road Signage

  • Platforms

  • Barricades

  • Lighting

  • Bosun

  • Ladders

  • Man Cage

  • Fire Extinguisher

8. HOT WORK

  • Has the area been cleared of combustible materials for 15m ?

  • Have all drains within 15m been covered with a wet fireproof blanket ?

  • Will hot work be performed in the Confined Space ?

  • Are appropriate fire extinguishes on site ?<br>List the type of Extinguishers .

  • Is a water hose available & tested on site ?<br>If no, list precautions taken to substitute a water hose.

  • Is extra ventilation required ?<br>If "YES" what type and where will it be located.

  • All power leads clear of pipelines ?

  • All power leads clear of access way ?

  • Will the Hot works release toxic vapours ?<br>If "YES", describe the controls to be implemented to enable Hot Works to be performed safely.

8.1. Welders

  • Are welding machines/gas bottles at least 8m from the manhole/pit entry ?

  • Are electric welders earthed ?

  • Are welders serviced to manufacturers specifications ?

  • Welders Name & Signature

8.2. Authority to perform "HOT WORKS" works

  • I have checked the above conditions and consider it safe to carry out this work.

  • Name & Signiture

  • Select date

9. CITY WEST WATER ENTRY

  • CONTACT CITY WEST WATER FOR ENTRY TIME - 9313 8499

  • Time phoned IN (Entry)

  • Time of intended EXIT

  • CWW Operator Name

10. APPROVAL TO ENTER

  • The Confined Space described in this Entry Checklist is in my opinion safe to enter using precautions listed above and all persons are properly trained to perform this work.

  • Name and Signature

  • Select date

11. JOB COMPLETION

  • All persons have left the Confined Space. No further Entries Permitted without New Permit

  • Name and Signature

  • Select date

12. CITY WEST WATER EXIT

  • CONTACT CITY WEST WATER FOR EXIT TIME - 9313 8499

  • Time of EXIT

  • CWW Operator Name

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.